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Poststroke Depression: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association
Abstract
Poststroke
depression (PSD) is common, affecting approximately one third of stroke
survivors at any one time after stroke. Individuals with PSD are at a
higher risk for suboptimal recovery, recurrent vascular events, poor
quality of life, and mortality. Although PSD is prevalent, uncertainty
remains regarding predisposing risk factors and optimal strategies for
prevention and treatment. This is the first scientific statement from
the American Heart Association on the topic of PSD. Members of the
writing group were appointed by the American Heart Association Stroke
Council’s Scientific Statements Oversight Committee and the American
Heart Association’s Manuscript Oversight Committee. Members were
assigned topics relevant to their areas of expertise and reviewed
appropriate literature, references to published clinical and
epidemiology studies, clinical and public health guidelines,
authoritative statements, and expert opinion. This multispecialty
statement provides a comprehensive review of the current evidence and
gaps in current knowledge of the epidemiology, pathophysiology,
outcomes, management, and prevention of PSD, and provides implications
for clinical practice.
Introduction
Depression occurs in approximately one third of stroke survivors at any one time1 and is associated with poor functional outcomes2 and higher mortality.3
Although poststroke depression (PSD) is one of the most common
complications after stroke, few guidelines exist regarding assessment,
treatment, and prevention of PSD. This scientific statement summarizes
published evidence on the causes, predisposing factors, epidemiology,
screening, treatment, and prevention of PSD; illuminates gaps in the
literature; and provides management implications for clinical practice.
Methods
Writing
group members were nominated by the committee chair on the basis of
their previous work in relevant topic areas and were approved by the
American Heart Association Stroke Council’s Scientific Statement
Oversight Committee and the American Heart Association’s Manuscript
Oversight Committee. Multiple disciplines were represented, including
neurology, psychiatry, psychology, neurorehabilitation, primary care,
epidemiology, biostatistics, and nursing. The writing group met by
telephone to determine subcategories to evaluate. These included 9
sections that covered the following: incidence, prevalence, and natural
history; pathophysiology; predictors; functional outcomes; quality of
life (QOL); healthcare use; mortality; screening; and management and
prevention. Each subcategory was led by a primary author, with 1 to 3
additional coauthors. Full searches of PubMed, Ovid MEDLINE, Ovid
Cochrane Database of Systematic Reviews, Ovid Central Register of
Controlled Trials databases, Internet Stroke Center/Clinical Trials
Registry (http://www.strokecenter.org/trials/), and National Guideline Clearinghouse (http://guideline.gov/)
were conducted of all English-language articles on human subjects,
published through February of 2015. The evidence was organized within
the context of the American Heart Association Framework. Drafts of
summaries and suggestions/considerations for clinical practice were
circulated to the entire writing group for feedback. Sections were
revised and merged by the Chair. The resulting draft was reviewed and
edited by the Vice-Chair, and the entire committee was asked to approve
the final draft. Changes to the document were made by the Chair and
Vice-Chair in response to peer review, and the document was again sent
to the entire writing group for suggested changes and approval. A
summary of findings is available in the Table.
Table.
Summary of Findings
Incidence, Prevalence, and Natural History of PSD
Depression
is common after stroke, affecting approximately one third of stroke
survivors at any one time after stroke (compared with 5%–13% of adults
without stroke), with a cumulative incidence of 55%.4–6
Hackett et al performed a systematic review and meta-analysis of 51
studies conducted before June 2004 and revealed a pooled frequency
estimate of PSD of 33% (95% confidence interval [CI], 29%–36%).7
All studies included ischemic stroke, most included intracerebral
hemorrhage, and the majority excluded subarachnoid hemorrhage and
transient ischemic attack. Valid methods were used to ascertain
depression in these studies. The primary end point was the proportion of
patients who met the diagnostic category of depression, which included
the following: (1) depressive disorder, depressive symptoms, or
psychological distress, as defined by scores above a cut point for
abnormality on a standard scale; (2) major depression, or minor
depression (or dysthymia) according to the third, fourth, and fifth
editions of the Diagnostic and Statistical Manual of Mental Disorders,
or other standard diagnostic criteria using structured or
semistructured psychiatric interviews. Ayerbe et al’s subsequent
systematic review and meta-analysis of 43 cohorts published before
August 2011 (n=20 293) revealed a similar pooled frequency of PSD of 29%
(95% CI, 25%–32%).8
The frequency remained fairly constant for the first year after stroke
and diminished slightly thereafter (28%; 95% CI, 23%–34% within 1 month
of stroke; 31%; 95% CI, 24%–39% at 1–6 months; 33%; 95% CI, 23%–43% at 6
months to 1 year; and 25%; 95% CI, 19%–32% beyond 1 year). Only 5
studies in Ayerbe et al’s systematic review reported other measures of
natural history of PSD: incidence in year 1 ranged from 10% to 15% (2
studies); cumulative incidence ranged from 39% to 52% (3 studies with
follow-up periods between 1 and 5 years); and 15% to 50% of patients
with PSD within 3 months of stroke recovered 1 year later. All
longitudinal studies revealed a dynamic natural history, with new cases
and recovery of depression occurring over time.8 Little is known about whether the natural course of PSD differs in those with a history of depression before stroke.
Hackett et al updated their systematic review and meta-analysis in 20141
to include all published observational studies with prospective
consecutive recruitment of stroke patients and assessment of depression
or depressive symptoms at prespecified time points (until May of 2013;
61 studies; n=25 488; 29 cohorts were also in Ayerbe et al’s review).
Their study revealed similar results, with depression present in 33%
(95% CI, 26%–39%) at 1 year after stroke, with a decline beyond 1 year:
25% (95% CI, 16%–33%) up to 5 years, and 23% (95% CI, 14%–31%) at 5
years.1
Prevalence of PSD was lower beyond 1 year: Subgroup analyses revealed a
pooled prevalence estimate of 31% (95% CI, 27%–35%) for the 48 studies
(n=23 654) including individuals with a history of depression; 34% (95%
CI, 29%–39%) for the 25 studies (n=19 218) including individuals with
aphasia; and 33% (95% CI, 28%–38%) for the 25 studies (n=5658) of people
with first-ever stroke.1
In
Hackett’s and Ayerbe’s meta-analyses, the prevalence rates did not
differ significantly over time during the first year after stroke
(within 1 month from stroke, 1–6 months, or 6–12 months) or by setting
(hospital, rehabilitation, or population based). The studies included in
Hackett’s and Ayerbe’s reviews were heterogeneous in nature, using a
variety of methods to diagnose depression and different thresholds for
the same scale. The hospital- and rehabilitation-based studies had
numerous exclusion criteria (such as excluding those with a history of
depression), thus limiting their generalizability. Statistical quality
and presentation of methods and results were poor in many studies, and
important covariates (such as history of depression) were not included
in multivariable models in most studies. Few of the multivariable models
were likely to be stable as the ratio of events per variable in the
model met or surpassed the recommended minimum.
In
summary, approximately one third develop PSD at some point after stroke.
The frequency is highest in the first year, at nearly 1 in 3 stroke
survivors, and declines thereafter.
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